Caregiver Designation Form

[Spliff Twister]

Designation of Primary Caregiver

As per California Health and Safety Code §11362.5

I hereby certify that I am a patient suffering from serious illness and have obtained a recommendation or approval from a licensed physician in the state of California to use medical cannabis (marijuana) in treating my illness. A copy of my recommendation may be attached hereto.

I hereby designate the individual described below as my Primary Caregiver,


in accordance with California Health and Safety Code §11362.5(d) and §11362.5(e), which reads as follows:
(d) Section 11357, relating to the possession of marijuana, and Section 11358, relating to the cultivation of marijuana, shall not apply to a patient, or to the patient s primary caregiver, who posses or cultivates marijuana for the personal medical purposes of the patient upon the written or oral recommendation or approval of a physician.
(e) For the purposes of this Section, primary caregiver means the individual
designated by the person exempt under this act who has consistently assumed responsibility for the housing, health, or safety of that person.
I agree that I will consistently rely on the individual described below as the primary source of medical cannabis as a matter of my personal health and safety. This designation shall remain in effect (1)
for one year from the date below, (2) until I revoke this designation, or (3) until I designate another individual as my primary caregiver.


Dated: ____________________

Patient Name (print clearly) Primary Caregiver Name (print clearly)

Patient Signature Primary Caregiver Signature


NOTICE TO LAW ENFORCEMENT: Pursuant to the Constitution of the State of California,
Amendment III, Section 3.5(c), state enforcement officials have no power

to refuse to enforce

[merickson]

Thanks for the form!

[Spliff Twister]

Yup no worries I had copies at my house and they had come in handy so I figured they might come in handy for others too.

[420]

i spruced it up a bit for you guys.
http://www.420times.com/images/docum...egiverform.doc

[HappyKitty]

Thanks 420, looks great!

[Pinch]

Thanks for the form. Good stuff!

[Spliff Twister]

Looks good thanks 420!

[acidblue]

How many caregivers am i allowed to have??

[Spliff Twister]

3 at the most is the safe bet but really I think as many as you want. Everytime you go to a co-op you are making them a caregiver so I must have a 100 but only one real caregiver